The federal Affordable Care Act (ACA) included an increase in reimbursement to eligible primary care physicians for specified services provided from January 1, 2013 through December 31, 2014. Payments for services rendered to Medi-Cal patients will be reimbursed at Medicare rates for the two-year period.

However, according to DHCS and CMS policy, total payment for services rendered may not exceed a provider's billed charges. Due to system limitations at the DHCS, providers may be restricted from billing their usual and customary rates on the PM-160 billing form. In most cases, providers have adapted to this restriction by billing at the expected Medi-Cal reimbursement rate for services provided to Child Health and Disability Prevention Program (CHDP) participants. This has created a problem for physicians anticipating the higher reimbursements, as according to DHCS and CMS policy, the providers have been paid at billed charges and are not owed additional ACA reimbursement. As a result, millions of dollars in payments to California physicians have not been released.

CalOptima and other California managed care plans have been working with the DHCS for several months to develop a solution that wouldn't require physicians to re-bill all eligible CHDP claims in order to obtain the increase. At the urging of physician advocacy groups such as CMA, OCMA and other stakeholders, the DHCS has agreed to a workaround that would allow these practices to be paid at the higher rate without the inconvenience of rebilling each claim.

DHCS recently released an online form where providers may attest to their usual and customary rates for CHDP services, allowing the practice to receive the higher reimbursement intended by the ACA rate increase. This attestation must be completed by November 28, 2014. The form may be found online at: http://files.medi-cal.ca.gov/pubsdoco/ACA/articles/acanews_23115_1.asp

DHCS recently announced it intends to make an interim payment on CHDP claims in December, with a true up to occur in 2015.